The interpreting physician must prepare a written report containing the results of each examination in addition to the following information:
Name of the patient and an additional patient identifier
Date of the examination
Name of the interpreting physician
An overall final assessment (The ACR strongly recommends that the assessment be categorized into one of the BI-RADS®7 final assessment categories, outlined in the table below)
The interpreting physician’s concise written report should be organized according to the following structure:
Comparison with previous studies, if available and pertinent
Statement of scope of examination (targeted or survey) and technique used
Analysis of the significant lesion(s) or finding(s)
Correlation with physical, mammographic or MRI finding(s)
Overall Final Assessment
Probably Benign Finding: Short-interval follow-up suggested
Suspicious Abnormality: Biopsy should be considered
Highly Suggestive of Malignancy: Appropriate action should be taken
Known Biopsy-Proven Malignancy: Appropriate action should be taken
In cases where no final assessment can be assigned due to incomplete work-up, the BI-RADS® Category 0 (Assessment is Incomplete: Need Additional Imaging Evaluation) should be used and reasons why a final assessment cannot be made provided. The ACR believes that a meaningful audit of examinations requires that the recommendations for recall imaging (BI-RADS® Category 0) also be considered “positive” and thus recommends that the facility collect and review outcome data on Category 0 exams.
The written report, signed by the interpreting physician, must be provided to the patient’s health care provider within 30 days of the examination date. If the assessment is “suspicious abnormality” or “highly suggestive of malignancy,” reasonable attempts must be made to communicate this to the health care provider (or designee) as soon as possible. The ACR and the FDA recommend that this communication occur within 3 business days.
The facility should not submit documentation of reporting with the accreditation materials; maintenance of reporting is verified during site visits.
Further guidance is available in the ACR Practice Guideline for Communication of Diagnostic Imaging Findings and in excerpted text from the BI-RADS Atlas.
Revision History for this Article
Description of Revision(s)
Article created; FAQs incorporated; No criteria changes
|Previous: QA: Breast Ultrasound||Next: Clinical Testing: Breast Ultrasound|